Government regulators have warned that failures in care at Parkland Memorial Hospital pose “an immediate and serious threat to patient health and safety,” and ordered it to submit a plan to remedy the problems within two weeks or lose federal funding.

In a letter delivered Tuesday to Parkland’s chief executive, Dr. Ron Anderson, the U.S. Centers for Medicare & Medicaid Services cites deficiencies under nine regulations. They include emergency care, infection control, nursing services and governance. Specific problems were not disclosed in the letter, which CMS shared with The Dallas Morning News under the Freedom of Information Act.

Anderson acknowledged the seriousness of the violations.

“We have a tremendous responsibility to get this right — to address the deficiencies identified by CMS — and to do so as quickly and thoroughly as possible,” he said in a written statement. “It is our obligation to the Dallas community and, most importantly, to our patients to provide care that is safe, of high quality and consistent with all state and federal regulations.”

Anderson declined to respond to questions from The News about the findings and how a potential funding cutoff would affect the hospital.

The action, which CMS described as rare, came after a top-to-bottom inspection of the Dallas County public hospital last month.

“Unless the serious and immediate threat to patient health and safety is removed, your hospital’s Medicare agreement will be terminated on September 2, 2011,” the letter stated. It referred to reimbursements the hospital receives from federal programs for the elderly, poor and disabled.

CMS told Parkland that it has until Aug. 20 to submit an acceptable correction plan, to be followed by another inspection to ensure compliance.

Federal officials say the inspection’s specific findings, which were delivered separately to Parkland in a report, will be released publicly after Parkland provides an official response.

David Wright, deputy regional administrator for CMS in Dallas, said two violations relating to infection control and emergency care issues are so serious they triggered “immediate jeopardy” status.

“That is the most severe finding we can have in a hospital, and it requires immediate attention,” Wright told The News. Every year, only two or three hospitals among the more than 400 statewide face such measures, he said.

Immediate jeopardy status — tied to the emergency care and infection control practices — can result from discovery of a pattern of problems or a single case reflecting serious breakdowns in patient care, Wright said. In Parkland’s case, “we generally identified systemic issues that need to be addressed.”

While CMS has taken one of its most extreme steps to force compliance, Wright declined to comment on the likelihood of Parkland losing its funding.

Heightened scrutiny

CMS rarely terminates a hospital’s Medicare and Medicaid funding. Only two Texas hospitals have lost certification since 2005, one in Houston and in another in San Benito, according to the agency. Both were small hospitals with fewer than 100 beds. Parkland has 735.

This year, Parkland expects Medicare and Medicaid to provide nearly half of its patient revenue, or $226 million. It also gets an additional $191 million in Medicaid subsidies awarded annually to health care providers that serve a disproportionate share of indigent patients. The total amount from both programs — $417 million — represents about 35 percent of Parkland’s total budget.

If payments were stopped, it’s unclear how the hospital would deal with such a blow. The hospital would have to reapply for certification and demonstrate compliance, a period that could stretch on for months.

Additionally, because one of the new violations involves the federal Emergency Medical Treatment and Labor Act, Wright said, the hospital also could face yet another fine from the inspector general of the U.S. Department of Health and Human Services. Last month, Parkland paid the maximum $50,000 fine under EMTALA, stemming from the 2008 death of Mike Herrera, who languished for more than 15 hours in the emergency room.

In the past five years, the government cited Parkland nine times for regulatory failures involving patient care. Last month, a nine-member team of inspectors from CMS and the Texas Department of State Health Services spent two weeks examining all areas of the hospital. A state official characterized it as “one of the largest surveys of its kind due to the hospital’s size and the scope of services it provides.”

That survey was prompted by the Feb. 10 death of psychiatric patient George Cornell. In May, regulators found that his rights were repeatedly violated when he was pinned stomach-down to the floor for as long as 25 minutes total without a doctor’s order. It also said Parkland failed to provide proper nurse monitoring or adequate staff training. Since 2010, three patients in the psychiatric emergency department have died there or shortly after leaving.

CMS’ letter to Anderson also cited Parkland for violating regulations that deal broadly with medical screenings, physicians working on call, sign posting and transfers of patients. These regulations include hundreds of protocols, making it difficult to know which ones are at issue.

Concerns identified

The hospital was notified that it ran afoul of the federal standard for “compliance with laws,” which spans everything from certification of doctors to budget matters. Under infection control, the hospital failed to comply with rules governing sanitary conditions to avoid infections and communicable diseases.

“I think the message we would give patients out there is that the system we have is working,” Wright said. “We’ve identified concerns at Parkland, and the expectation is that they’ll do whatever’s necessary to address concerns. That’s the way it should work.”

In the wake of CMS’ findings in the Herrera and Cornell deaths, Parkland said it had taken steps to change a number of procedures.

The hospital failed to report Cornell’s death to state and federal agencies. Regulators learned about the case from The News’ coverage.

Lauren McDonald, chairwoman of the Parkland Board of Managers, said she was briefed on the report but had not seen it herself. She declined to share specifics.

McDonald acknowledged the seriousness and rarity of “immediate jeopardy” findings but added that “any recommendation by CMS is to be taken seriously.”

When asked whether the hospital had disagreed with any CMS findings, she said that “I don’t think it’s our place to say whether we agree or disagree.”

She added, “Whenever CMS comes to the hospital, it’s kind of like the military. They have the authority. Whether you agree or not is not pertinent. You just have to go ahead and make the changes and corrections that they suggest.”

McDonald said the board has “complete confidence” that the hospital’s staff will craft a corrective plan by the deadline that satisfies CMS.

“We should be able to keep our standing,” she said. “We have to make the corrections as suggested. They will be done, and we’ll be back on track.”

Staff writer Sherry Jacobson contributed to this report.

mmoffeit@dallasnews.com;

rdunklin@dallasnews.com

CMS FINDINGS AT PARKLAND

Parkland Memorial Hospital has been found in violation of nine federal regulations after a sweeping health and safety review last month. Those requirements cover a range of areas, from emergency care to staffing to hospital administration. The Centers for Medicare & Medicaid Services will not publicly discuss specific deficiencies until it receives a corrective plan from the hospital. But here is a summary of some of the general standards cited:

Appropriate transfer: Prohibits the transfer of an emergency patient who hasn’t been stabilized unless certain conditions are met and medical records document the decision-making.

On-call physicians: Requires a list of physicians on call for duty after an initial examination to provide treatment to stabilize an emergency patient.

Nursing services: Covers proper staffing levels, licensing of nurses, how drugs can be administered and the need for patient-care plans.

To post a comment, log into your chosen social network and then add your comment below. Your comments are subject to our Terms of Service and the privacy policy and terms of service of your social network. If you do not want to comment with a social network, please consider writing a letter to the editor.

UT Southwestern Medical Center and Parkland Memorial Hospital are known for their contributions to medical research and public health. But have those accomplishments come at a cost to quality healthcare? The Dallas Morning News investigates patient safety and allegations of lax supervision of doctors in training at the public institutions.